A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop
The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? A) Cardiovascular system
B) Respiratory system
C) Endocrine system
D) Neurovascular system
D
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The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
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The nurse is caring for a patient with an immunodeficiency who has experienced sudden malaise. The nurse's colleague states, "I'm pretty sure that it's not an infection, because the most recent blood work looks fine."
What principle should guide the nurse's response to the colleague? A) Immunodeficient patients will usually exhibit subtle and atypical signs of infection. B) Infections in immunodeficient patients have a slower onset but a more severe course. C) Laboratory blood work is often inaccurate in immunodeficient patients. D) Immunodeficient patients do not develop symptoms of infection.
Which intervention is appropriate for a client receiving palliative care? (Choose all that apply.)
1) Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation 2) Administering intravenous dopamine to raise blood pressure of a patient with end-stage lung cancer 3) Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4) Administering a medication to relieve the nausea of a patient with end-stage leukemia
A stimulus or activity that is measured to examine the effect created by the independent variable best describes a(n) _____ variable
a. Independent b. Demographic c. Extraneous d. Dependent
To maximize therapeutic care to a newly admitted suicidal patient on days 1 and 2 of hospitalization, the nurse will:
a. Select appropriate community resources for referral. b. Identify patient areas of weakness and deficiency. c. Encourage the patient to express psychological pain. d. Refute delusional thinking by logical argument and reinforcement.